Healthcare Provider Details

I. General information

NPI: 1588072300
Provider Name (Legal Business Name): GRACE DOMINIQUE MILLER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2014
Last Update Date: 12/01/2022
Certification Date: 12/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

371 E 51ST ST
BROOKLYN NY
11203-3507
US

IV. Provider business mailing address

604 JEFFERSON AVE APT 3
BROOKLYN NY
11221-7331
US

V. Phone/Fax

Practice location:
  • Phone: 917-651-5138
  • Fax:
Mailing address:
  • Phone: 516-939-3005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number761864
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number761864
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number314147
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number761864
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: